Options Counseling Release of Information Authorization


 

I authorize Options Counseling & Family Services to use and disclose a copy of the specific health information described below regarding:

Name of Individual:     DOB:

Options Location:

My information may be released to the following Agency or Name of Individual :    
Address:  
Phone : Fax :

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. Information used or disclosed on this authorization may be subject to redisclosure and could no longer be protected by federal and state laws on use and disclosure. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information. Initial each documentation category you are authorizing.

Drug/Alcohol Treatment : HIV, Diagnosis/Treatment :  Genetic Testing :
Social Services :  Mental Health Services :   Medical/Psychiatric Treatment :    
Other, as listed :

For the purpose of: 

unless I specify otherwise:Items not to be included:

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. 

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. To revoke this authorization, send a written statement to:
Options Medical Records, 3500 Chad Dr. #350, Eugene OR 97408.

If client is 14 years of age or older only they can authorize releases of information and must be the signer of this document.
Authority :

 

 

To those receiving information under this authorization: The information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.  

I have read this authorization and I understand it. Unless revoked, this release will expire one year from date of  signature or upon the applicable date or event, as listed:  

Leave this empty:

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Options Counseling & Family Services https://wp.options.org
Signature Certificate
Document name: Options Counseling Release of Information Authorization
lock iconUnique Document ID: 2ceba8e8859b7210313c03820ce62d8353c2cd8d
Timestamp Audit
April 27, 2020 8:17 am PDTOptions Counseling Release of Information Authorization Uploaded by Adam Falk - adam.falk@options.org IP 50.240.25.195
April 28, 2020 11:40 am PDTAdam Falk - adam.falk@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 28, 2020 11:46 am PDTAdam Falk - adam.falk@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 28, 2020 11:53 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 28, 2020 1:19 pm PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 29, 2020 9:40 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 29, 2020 9:42 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 4, 2020 7:31 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 4, 2020 7:32 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:30 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:31 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:32 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:33 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195